Healthcare Provider Details

I. General information

NPI: 1629362645
Provider Name (Legal Business Name): ELIZABETH ANN HENRY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 FAIRFAX TRFY
KANSAS CITY KS
66115-1307
US

IV. Provider business mailing address

12103 STATE ROUTE 7
LAKE LOTAWANA MO
64086-9165
US

V. Phone/Fax

Practice location:
  • Phone: 913-573-7053
  • Fax: 913-573-7001
Mailing address:
  • Phone: 816-853-3077
  • Fax: 913-573-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2011017381
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number53-75912-101
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-75912-101
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: